INITIAL CONTACT QUESTIONAIRE
Water Pollution Complaint Form
Notification/Request
Contact Name:
Title:
Phone:
Company/Agency:
Division:
Contact Address:
City:
State:
Zip:
Comments:
Location
Affected Address:
City:
State:
Zip:
Extent of Impact:
Reference:
Material
Possible Source:
Possible Type of Material:
Approximate Distance to Storm Drain:
Approximate Size of Spill:
How fast is spill increasing in size?
How fast is spill moving toward storm drain?
Is there an odor present?
Describe Odor:
